This blog is totally independent, unpaid and has only three major objectives.
The first is to inform readers of news and happenings in the e-Health domain, both here in Australia and world-wide.
The second is to provide commentary on e-Health in Australia and to foster improvement where I can.
The third is to encourage discussion of the matters raised in the blog so hopefully readers can get a balanced view of what is really happening and what successes are being achieved.

Sunday, May 22, 2011

The Scale of the Mess In the UK Health IT Program Is Just Terrifying! Hang On To Your Wallet!

I did a short blog on the reporting on the National Audit Office (NAO) report on the National Program for Health IT a few days ago.

I have now had time to have a browse of the reports. They are pretty blunt and make riveting reading. This extended key quote gets the flavour.

The National Programme for IT in the NHS: an update on the delivery of detailed care records systems

The rate at which electronic care records systems are being put in place across the NHS under the National Programme for IT is falling far below expectations and the core aim that every patient should have an electronic care record under the Programme will not now be achieved.

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"The original vision for the National Programme for IT in the NHS will not be realised. The NHS is now getting far fewer systems than planned despite the Department paying contractors almost the same amount of money. This is yet another example of a department fundamentally underestimating the scale and complexity of a major IT-enabled change programme.

"The Department of Health needs to admit that it is now in damage-limitation mode. I hope that my report today, together with the forthcoming review by the Cabinet Office and Treasury, announced by the Prime Minister, will help to prevent further loss of public value from future expenditure on the Programme."

Amyas Morse, head of the National Audit Office, 18 May 2011

The rate at which electronic care records systems are being put in place across the NHS under the National Programme for IT is falling far below expectations and the core aim that every patient should have an electronic care record under the Programme will not now be achieved. Even where systems have been delivered, they are not yet able to do everything that the Department intended, especially in acute trusts. Moreover, the number of systems to be delivered through the Programme has been significantly reduced, without a commensurate reduction in the cost.

Today's NAO report concludes that the £2.7 billion spent so far on care records systems does not represent value for money. And, based on performance so far, the NAO has no grounds for confidence that the remaining planned spending of £4.3 billion on care records systems will be any different.

The original aim of the Programme was for every patient to have an electronic care record by 2010. The systems the Department contracted its suppliers, BT and CSC, to deliver are now not all expected to be in place until 2015-16. Even so, based on performance so far, it is unlikely that the remaining work in the North, Midlands and East, where just four of 97 systems have been delivered to acute hospital trusts in seven years, can be completed by 2016 when the contract with CSC expires. Indeed, in order to meet the revised deadline, over two systems a month would need to be delivered in this Programme area over the next five years.

Progress in delivering care records systems varies dramatically between regions. There has been more progress in London in some health settings, although no GP practices are now receiving a system through the Programme and the number of systems in acute hospital settings has halved.

Where care records systems are in place, they are not yet delivering what the Department had expected. In acute trusts, the systems are mainly providing administrative benefits, rather than the expected clinical ones, such as prescribing and administering drugs in hospitals. The Department has now changed its approach and moved away from its intention to replace systems wholesale, instead, building on and using trusts' existing systems. To do this the Department estimates it will cost at least £220 million to get the systems to work together.

Publication details:

HC: 888, 2010-2012

ISBN: 9780102969689

----- End Quote

Reading through the documentation there are some vital points:

First this report is the third released on the program - with the first done in 2006 and the second in 2008. Each of the reports has become increasingly pessimistic yet the spending and effort has continued without any apparent checkpoint and re-assessment. Result has been what was an eight year program winding up being a 15 to 16 year program. Never the less our Government seems to imagine that kicking off a form of national program - with none of the levers and controls held by the NHS over all parts of the health system - is going to result in a working national PCEHR System in a couple of years - you can really only wonder what they are smoking. (I know Australians and good but are we really that good?)

My fear is that what will happen is that we will see the initial 2 years funding continued for the PCEHR - dig ourselves into a deeper and deeper ditch - and despite recognising it is not going well not do the fundamental reviews that will be (and already are) needed.

Second this report makes it clear that when Government crosses swords with smart corporates (like CSC and BT) that it is possible to contract for something, deliver less and still get paid. There is a red light flashing warning here for DoHA. May be they should hire a fox to manage their henhouse to save themselves from this outcome!

Third it is alarming that it seems the clinical systems have been the ones that have been the most under delivered. The same, to varying degrees is also seen here - reminding us again just how hard doing clinical systems on any scale seems to be.

Fourth the first bold paragraph above just re-enforces the point about how long this takes before results are really seen. Making continuing funding contingent on the results of the first 2 years is utterly absurd!

Fifth the progress that has been made with the N3 Network, PACS and other nonclinical systems reminds us all that building basic infrastructure is the easy bit - the clinical applications and use of those is very much the ‘hard bit’!

Last, the scale of the mess here means we really need to challenge the wisdom of large national programs of this sort and come up with a fundamentally different way to approach things, as this really does not appear to be a good way forward.

On balance I still think the National E-Health Strategy, with an emphasis on local provider systems and clinical information flows before moving to shared records was correct and this report and the earlier reviews by Prof Trisha Greenhalgh just confirm that view.

4 comments:

It's really very simple -manage your vendors. Too many health departments are prepared to enter into "partnerships" with vendors. This seems to make them abandon all vendor governance and allow vendors to dictate deliverables, etc.Understand that vendors have no real interest in your internal "wants" and "needs". They view you as a cash cow to turn a profit for the company, nothing more.Health IT vendors act like used car salesmen - promise you what they think you want, oversell their product's capabilities, and often ignore your concerns once they have got your money. They hardly have a stunning history of delivering what is promised or contracted for. Look at how they industry responded to the Queensland Gov. suing TrakHealth.You have a contract, you have a crown law department - manage your vendors.

The problem is that the management is political rather than technical and the political management is very experienced at making failure look like success - remember how Healthconnect resulted in the "eHealth is Change Management finding"

If we use proven working standards and compliance testing, that is real, then things would improve. Computers don't use the political fudging however, they are binary, it's either right of wrong and we will get nowhere until these programs are managed by technical people with domain expertise, who know this.

Are we currently using proven working standards managed by people with domain expertise? We are not, and as a result the chance of failure is very high.

Exactly right Andrew.But we continue to enter into these fluffy, feel-good arrangements with vendors that talk about "partnerships" and "moving forward together" and "in this for the long term".

All these sound fine to political people, because they deal with these weasel words every day. But this is just chum in the water for vendor sharks.

Vendors do not want compliance testing as it pins them down to specific deliverables. I've sat in vendor meetings where I have been told by the vendor that load testing is not required as "it doesn't really tell you anything". When that project went live and it was found that the system could not cope with the load, it was all I could do to bite my tongue.

Sorry, but my view of vendors is very cynical at the moment as another project is heading for failure due to not managing their vendor and demanding that the vendor deliver what is in the contract.

John Halamka at http://geekdoctor.blogspot.com/2011/05/should-we-abandon-cloud.html has a lot of relevant points. So, too, does Tim Harford in http://timharford.com/2011/05/lessons-in-adapting-from-the-war-in-iraq/ on management of complexity from an economist's angle.